Pediatric Coding Alert

Yes, it's true you don't have to report external cause of morbidity codes (V00-Y99). But why wouldn't you? After all, they can provide benefits to your practice, to medical researchers, and to policy makers.

Oh, and did we mention that forgetting to add these codes could create problems for you and your provider? Read on, and learn how reporting cause, intent, place, and status can help you as you help others.

Know Reasons Behind External Cause Codes

ICD-10 defines the external cause codes as codes that "capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred the activity of the patient at the time of the event, and the person's status (e.g., civilian, military)."

Examples of external codes that describe these four factors that you could use in a pediatric setting include the following:

Cause: W55.03XX (Scratched by cat)

Intent: X78.1XXX (Intentional self-harm by knife)

Place: Y92.003 (Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause)

Most coders are familiar with the ICD-10 guidelines for reporting external cause. In part, they state that "there is no national requirement for mandatory ICD-10-CM external cause code reporting." However, the guidelines go on to note that external cause codes may be required when subject to "a state-based ... reporting mandate" or by "a particular payer."

One such state is Louisiana. According to author Susan Chapman, the Louisiana Health Care Specifications Manual states that "Diagnosis codes reported in the range of ... S00.00xx–T88.99XXS (ICD-10) require the reporting of a valid External Cause-of-Injury Code."

"While external cause codes are not valid as principal diagnosis codes," Chapman goes on to note, in Louisiana, "if the principal diagnosis code is trauma-related and there is no external cause code, then the record will be rejected." (Source: http://www.fortherecordmag.com/archives/0617p24.shtml)

... and When You Don't

It is also important to note that, even if a particular payer or your state requires you to report an external cause code, you won't have to use some codes if the injury has already been reported by another provider, such as an emergency department (ED). The American Academy of Pediatrics (AAP) reminds coders that "the place of occurrence, activity and status are only at the initial injury encounter (ie, only reported once per injury). Therefore, if the patient was seen in the emergency department for an injury, your office would not code the additional details, only the external cause" (Source: https://www.aap.org/en-us/Documents/coding_faq_coding_encounters_icd_10.pdf).

Report to Help Your Practice, Help Your Profession

There are also a number of reasons why you should report external causes for injuries even when outside agencies do not mandate them. For one thing, they can help benefit your practice immensely. Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC, believes that "external cause codes can be useful for understanding the conditions you're treating as quality-improvement opportunities might reveal themselves."

For example, suppose your provider sees a teenage football player and you record S06.0X1A (Concussion with loss of consciousness of 30 minutes or less, initial encounter) and W21.01XA (Struck by football, initial encounter). This, Blanchard argues, could well be an opportunity for your provider to initiate baseline concussion testing. Additionally, Blanchard argues, "efforts towards qualifying for things such as patient-centered medical home [PCMH] recognition and value-based care incentives can be bolstered by detailed external cause reporting."

And on a larger scale, Evan M. Gwilliam, writing in the American Academy of Professional Coders' (AAPC) blog, encourages coders to go a step further, noting that the codes provide "the opportunity to report enhanced detail [and] improve the process of data collection for researchers and policy makers."

Report to Stay Out of Trouble, Too

Above and beyond these reasons, there may also be compelling legal reasons for reporting external causes. You may not ever be required to testify in court over such codes, as employees of the University Medical Center were when they used an incorrect external cause code in the trial that convicted the murderer of New Orleans Saints footballer Will Smith (Source: http://www.fortherecordmag.com/archives/0617p24.shtml).

But claims reimbursement could hinge on the accuracy of your external cause coding.

Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, reminds coders that "many carriers honestly want to know if they are responsible for the payment of the visit. If the cause of the visit indicates that some other person or carrier could be responsible," Holle argues, "then the carrier will reject the claim and ask for further information, thus delaying payment."

Blanchard agrees, arguing that a claim to a payer that is missing a Y92 (Place of occurrence of the external cause) code could "trigger a claim edit to require proof that liability insurance at the place of occurrence doesn't supersede the medical carrier's responsibility for payment."

Ultimately, though, Holle reminds coders that the Chapter 20 codes "will help explain the situation and help justify the level of care claimed," while aiding in getting the claim paid quicker by providing further, detailed information to payers.